Pleural effusion...

Yesterday we reviewed a patient with a giant pleural effusion (after bouncing back from a short admission for pneumonia)

For a reminder of Light's criteria see the previous post HERE

notice the shifted trachea AWAY from the whiteout

For the guidelines of see this article

But some of the main points:

Exudative effusion can be divided  into:


Category 1:  Minimal, free-flowing effusion (< 10 mm on lateral decub CXR) and unknown culture/gram stain and unknown pH --> SIMPLE
Category 2: Small to moderate free-flowing effusion (> 10 mm and < 1/2 hemithorax) and negative culture and Gram stain and pH > 7.20 (i.e., an uncomplicated) 
Category 3: Large free-flowing effusion ( > 1/2 hemithorax) or Loculated or thickened parietal pleura or positive culture/Gram stain or pH < 7.20 (i.e., a complicated) 
Category 4: Frank pus  (Empyema)


• Categories 1 and 2 have good outcomes and do not usually require drainage. 

• Categories 3 and 4 have poor outcomes and generally require drainage. The panel reviewed the literature on the management of these effusions. 

Some  fun facts of pH: 
Can be low in infection and malignancy. 

<7.20 in parapneumonic infection is indication for drainage 

<7.20 in malignancy predicts a poor response to pleurodesis ( and a poor prognosis eg. a median survival of only 30 days)

some more respirology

Firstly, thanks again to Dr. Stephanie Leung who taught about chronic cough yesterday. 
Here is a link to a review on cough. (who knew there was a journal called "cough"?)


Today we went through a case that presented with dysphagia. Here is a good decision tree to direct your history.

He ended up having a large pleural effusion. This led us to a discussion on the classification of pleural effusion (transudative and excitative) as per Light's criteria (this wil take you to the reveiw article by Lights himself).

Reminder lights criteria predicts exudative effusion if ONE of:

• pleural protein / serum protien >0.5
• pleural LDH/ serum LDH >0.6
• pleural LDH > 2/3 upper limit of normal serum LDH

SPAG (serum-pleural albumin gradient) >12 points towards a transudative effusion in cases that clinically seem transudative but based on chemistry of the pleural tap have a exudative picture. (such as after diuresis)

This is the LINK to our procedure website that has a video and tips about thoracentesis.